Healthcare Provider Details

I. General information

NPI: 1902272669
Provider Name (Legal Business Name): HORIZON DENTAL NORTH END LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2015
Last Update Date: 08/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3810 N GARDEN CENTER WAY
BOISE ID
83703-5007
US

IV. Provider business mailing address

3810 N GARDEN CENTER WAY
BOISE ID
83703-5007
US

V. Phone/Fax

Practice location:
  • Phone: 208-853-5111
  • Fax:
Mailing address:
  • Phone: 208-853-5111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD4410OS
License Number StateID

VIII. Authorized Official

Name: DR. COLE W ANDERSON
Title or Position: CEO
Credential: DMD, MS
Phone: 208-343-0909